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MULTIPLE EMPLOYER WELFARE ARRANGEMENT

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					                       MULTIPLE EMPLOYER WELFARE ARRANGEMENT
                                 QUARTERLY STATEMENT

                          FOR THE QUARTER ENDED

                                                   (Name of MEWA)
Administrative Office
                                          Number                           Street


         City                              State                     Zip                Telephone Number
Mailing Address

         City                              State                     Zip
Date Established or Organized                                 Date Operations Commenced


Quarterly Statement Contact
                                             Name                                    Telephone Number

Internet Website Address

                              BOARD OF DIRECTORS (OR EQUIVALENT)
                         Name                                                       Title




STATE OF ALASKA                       )
                                      )
                                      )
                                               President,                                           Secretary,
                                               Treasurer being duly sworn, each deposes and says that they
are the above described officers (or equivalent) of said multiple employer welfare arrangement and that
this quarterly statement, together with all attachments and exhibits, to the best of their information,
knowledge and belief is a full, true, and correct statement of the condition and affairs of said arrangement
on
                     (Date)
                                                              President



Secretary                                                     Treasurer
Required Notarization of Signatures Above:                    Subscribed and sworn to before me this

                                                                     day of                         , 20

                                                              Signature
                                                              My commission expires:


Alaska Division of Insurance MEWA Financial Statement
(revised 06/09)                                           1
NAME OF MEWA

For the quarter ending                                 ________

                                            STATEMENT OF FINANCIAL CONDITION
                                                        ASSETS

                                                                                                                   December 31
                                                                                             Current Quarter
                                                                                                                    Prior Year

 1.    Bonds .........................................................................   $                     $

 2.    Stocks

       2.1 Preferred stocks ..................................................

       2.2 Common stocks...................................................

 3.    Cash on hand and on deposit.....................................

 4.    Short-term investments ..............................................

 5.    Write-ins for invested assets

       a.

       b.

       c.

       d.

 6.    Subtotal, cash and invested assets ............................

 7.    Uncollected contributions (pg. 7, line 12) ...................

 8.    Insurance recoverables for claims and claims
       adjustment expenses .................................................

 9.    Interest and other investment income due and
       accrued .......................................................................

 10. Receivable from employers (other than for insurance
     contributions) ..............................................................

 11. Furniture and equipment (cost less depreciation over
     useful life) ...................................................................

 12. Write-ins for other than invested assets

       a.

       b.

       c.

       d.

 13. TOTALS (lines 6 through 12d) ...................................



Alaska Division of Insurance MEWA Financial Statement
(revised 06/09)                                                              2
NAME OF MEWA                                                                           __________________________

For the quarter ending                             ________

                                         STATEMENT OF FINANCIAL CONDITION
                                             LIABILITIES AND RESERVES

                                                                                                            December 31
                                                                                      Current Quarter
                                                                                                             Prior Year

 1.    Claims unpaid (pg. 8, line 3) .......................................      $                     $

 2.    Unpaid claim adjustment expenses............................

 3.    Unearned contributions (pg. 7, line 5) ........................

 4.    Unearned investment income .....................................

 5.    Other expenses due or accrued .................................

 6.    Borrowed money ........................................................

 7.    Amounts withheld or retained for account of others ...

 8.    Excess of loss insurance premiums due but unpaid ..

 9.    Pass through premiums due but unpaid

 10. Write-ins for other liabilities

       a.

       b.

       c.

       d.

 11. Total liabilities (lines 1 through 10) .............................

       RESERVES

 12. Paid in and contributed surplus ..................................

 13. Earned surplus ...........................................................

 14. Write-ins for special surplus funds (voluntary and
     general contingency reserves and other special
     surplus other than liabilities ........................................

       a.

       b.

       c.

 15. Total reserves (lines 11 through 13c) .........................

 16. TOTALS (line 11 + line 15) .........................................
Alaska Division of Insurance MEWA Financial Statement
(revised 06/09)                                                        3
NAME OF MEWA                                                                                   __________________________

For the quarter ending                                  ________

                                                     STATEMENT OF OPERATIONS

                                                                                                                    December 31
                                                                                              Current Quarter
                                                                                                                     Prior Year

 1.    Contributions Earned (pg. 7, line 7) ............................                  $                     $

 2.    Claims incurred (pg. 8, line 7)
       net of insurance ($                                               ) ............

 3.    Expenses incurred:

       a. Claim adjustment ...................................................

       b. Administrative & Soliciting .....................................

 4.    Insurance allowances – expenses and experience
       refund .........................................................................

 5.    Total underwriting deductions (lines 2 through 4).......

 6.    NET UNDERWRITING GAIN (LOSS) (line 1 - line 5)

 7.    Net investment income earned ...................................

 8.    Net realized capital gains (losses) ..............................

 9.    NET INVESTMENT GAIN (LOSS) (line 7 + line 8) ....

 10. Other income

       a.

       b.

 11. NET GAIN (LOSS) (line 6 + 9 + 10) ...........................




Alaska Division of Insurance MEWA Financial Statement
(revised 06/09)                                                               4
NAME OF MEWA                                                                              _________________________

For the quarter ending                               _________

                                                RECONCILIATION OF RESERVES

                                                                                                               December 31
                                                                                         Current Quarter        Prior Year

 1.    Total reserves, beginning of year ...............................             $                     $

 2.    Net gain (loss) (page 4, line 11) .................................

 3.    Net unrealized capital gains (losses) ..........................

 4.    Write-ins for changes to reserves

       a.

       b.

       c.

 5.    Change in reserves for year to date
       (lines 2 through 4) .......................................................

 6.    Total reserves, end of quarter (line 1 + line 5)............

                                                     ADEQUACY OF RESERVES

                                                                                                               December 31
                                                                                         Current Quarter        Prior Year

 1.    Total reserves, end of quarter (line 6 above) .............                   $                     $

 2.    Minimum required reserves (30% of pg. 3, line 1 or
       other amount established)*.........................................

 3.    Excess (deficient) reserves (line 1 - line 2) ................


*Reserves must be maintained at no less than the greater of 30% of unpaid claim liability or the amount
recommended and certified by a qualified actuary as a minimum reserve. (AS 21.85.050)




Alaska Division of Insurance MEWA Financial Statement
(revised 06/09)                                                          5
NAME OF MEWA                                                                                   ____________________________

For the quarter ending                                  ________

                                                                           CASH FLOW

                                                                                                                Current Quarter   Dec. 31 Prior Year
 1.    Contributions collected net of insurance premiums paid ................                              $                     $
 2.    Claims and claims adjustment expenses paid ...............................
 3.    Underwriting expenses paid ...........................................................
 4.    Other underwriting income (expenses)...........................................
 5.    Cash from underwriting (line 1 – 2 – 3 + 4) ....................................
 6.    Investment income (net of investment expenses) ..........................
 7.    Other income (expenses) ...............................................................
 8.    Net cash from operations (line 5 + 6 + 7) .......................................
 9.    Proceeds from investments sold, matured, or repaid:
       a. Bonds .........................................................................................
       b. Stocks ........................................................................................
       c. Other invested assets ................................................................
       d. Net gains (losses) – cash, short-term investments ...................
       e. Miscellaneous proceeds ............................................................
       f. Total investment proceeds (lines 9a through 9e) ......................
 10. Other cash provided:
       a.
       b.
       c. Total other cash provided ..........................................................
 11. Total (line 8 + 9f + 10c) ...................................................................
 12. Cost of investments acquired (long-term):
       a. Bonds .........................................................................................
       b. Stocks ........................................................................................
       c. Other invested assets ................................................................
       d. Total investments acquired (lines 12a through 12c) ..................
 13. Other cash applied:
       a.
       b.
       c. Total other cash applied ............................................................
 14. Total (line 12d + 13c) ......................................................................
 Reconciliation of Cash and Short-term Investments
 15. Net change in cash and short-term investments (line 11 – line 14)
 16. Cash and short-term investments:
       a. Beginning of year .......................................................................
       b. End of year (line 15 + line 16a) ..................................................




Alaska Division of Insurance MEWA Financial Statement
(revised 06/09)                                                              6
NAME OF MEWA                                                                                     ___________________________

For the quarter ending                                  _________

                                                                CONTRIBUTIONS


 1.    Contributions ..............................................................................................      $

 2.    Excess of loss insurance premiums ...........................................................

 3.    Pass through insurance premiums (i.e. life insurance) ..............................

 4.    Net contributions (line 1 – line 2 - line 3) ....................................................

 5.    Unearned contributions prior year end .......................................................

 6.    Unearned contributions current year end ...................................................

 7.    Contributions earned (line 3 + line 5 – line 6) .............................................




                                         AGING OF UNCOLLECTED CONTRIBUTIONS

 8.    Current........................................................................................................

 9.    1 – 29 days overdue ...................................................................................

 10. 30 – 90 days overdue .................................................................................

 11. 91 – 120 days overdue ...............................................................................

 12. Over 120 days overdue ..............................................................................

 13. Total Uncollected Contributions (Lines 7 through 11) ................................
     (See Note A)



Note A: The Total of Uncollected Contributions is the receivable that is considered collectable. Do not
include in this schedule, or on Page 2, any receivable amounts that are not determined by management to
be collectable.




Alaska Division of Insurance MEWA Financial Statement
(revised 06/09)                                                               7
NAME OF MEWA                                                                                   ___________________________

For the quarter ending                                 _________


                                                                      CLAIMS

CLAIMS UNPAID – NET OF EXCESS OF LOSS INSURANCE


 1.    Reported claims in process of adjustment .................................................                      $

 2.    Estimated incurred but unreported claims ..................................................

 3.    Total claims unpaid (line 1 + line 2) ............................................................


CLAIMS PAID AND INCURRED – NET OF EXCESS OF LOSS INSURANCE

 4.    Claims paid .................................................................................................

 5.    Claims unpaid current year (from line 3) ....................................................

 6.    Claims unpaid prior year .............................................................................

 7.    Claims incurred (line 4 + line 5 – line 6) .....................................................


ANALYSIS OF UNPAID CLAIMS – PREVIOUS YEAR NET OF EXCESS OF LOSS INSURANCE

 8.    Claims paid during the year:

       a. On claims incurred prior to current year ................................................

       b. On claims incurred during the current year ...........................................

 9.    Claims unpaid liability at current year end:

       a. On claims incurred prior to current year ................................................

       b. On claims incurred during the current year ...........................................

 10. Total claims paid and unpaid on claims incurred in prior years (line 8a +
     line 9a)

 11. Claims unpaid at prior year end (pg. 3, line 1, prior year)...........................

 12. Deficiency (redundancy) (line 10 – line 11)

 13. Line 12 as a percentage of prior year reserves (pg. 3, line 14, prior year) .




Alaska Division of Insurance MEWA Financial Statement
(revised 06/09)                                                              8
NAME OF MEWA                                                                                  __________________________

For the quarter ending                               __________

                                                                 INTERROGATORIES


1. (a) Did the reporting entity implement any significant accounting policy changes? .........                                        Yes ( ) No ( )

     (b) If “yes," attach detailed explanation of accounting policy changes.

2. (a) Was money loaned during the quarter to any officer, director or trustee of the
       arrangement? .............................................................................................................     Yes ( ) No ( )

     (b) If "yes," attach detailed explanation of each loan.

3. (a) Does the arrangement own any investments in or have any outstanding loans to a
       participating employer or affiliate of a participating employer? ..................................                            Yes ( ) No ( )

     (b) If yes, attach a list of the investments and loans with full description, date acquired,
         statement value, and interest rate for each item.

4. (a) Has any change been made during the year of this statement in the articles,
       bylaws, agreements, trusts, or other documents or instruments describing the
       rights and obligations of the employers, employees and beneficiaries of the
       arrangement? .............................................................................................................     Yes ( ) No ( )

     (b) If "yes," furnish herewith a certified copy of the instrument as amended, if not
         previously submitted.

5. (a) If the reporting entity is subject to a management agreement, including third-party
       administrator(s), managing general agent(s), attorney-in-fact, or similar
       agreement, have there been any significant changes regarding the terms of the
       agreements or principals involved? ............................................................................                Yes ( ) No ( )

     (b) If "yes," furnish herewith a copy of the instrument as amended, if not previously
         submitted.

6. (a) Have there been any substantial changes in the organizational chart since the prior
       quarter end? ...............................................................................................................   Yes ( ) No ( )

     (b) If “yes,” attach an organizational chart.

7.    (a) Has the reporting entity been a party to a merger or consolidation during the period
          covered by this statement? ........................................................................................         Yes ( ) No ( )

     (b) If “yes,” give full information.

8. (a) Has this reporting entity had any Certificates of Authority, licenses or registrations
       (including corporate registration, if applicable) suspended or revoked by any
       governmental entity during the reporting period? (You need not report an action,
       either formal or informal, if a confidentiality clause is part of the written
       agreement.)? ..............................................................................................................    Yes ( ) No ( )

     (b) If “yes,” give full information.




Alaska Division of Insurance MEWA Financial Statement
(revised 06/09)                                                             9

				
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